Rotator Cuff

w/ Subacromial bursitis, tend to think what is the prime pain center w/ added compressive force?

supraspinatus tendinopathy (Subacromial Impingement Syndrome)

Pathoanatomical Diagnosis of Subacromial Pain Syndrome (SAPS)

Subacromial Impingement Syndrome: Subacromial bursitis

Rotator Cuff Tendinopathy/Dysfunction/Tears

Bicipital Tendinopathy

Superior Labral Anterior to Posterior (SLAP) Tear

rotator cuff disease progression (impacted by aging, compression of humeral head on acromion)

tendinopathy → Tendinosis/Degenerative Tendon → Tendon Tearing

The Degenerative Mircotrauma Model for Rotator Cuff Tears is age related; 50% chance of cuff tear after

60 y/o, repetitive mircoload leads to break down of tendon

which tendon is most commonly torn in rotator cuff?

Supraspinatus → Infraspinatus → Subscapularis

(Biceps may become involved in larger tears)

w/ a supraspinatus injury, stress moves onto

the biceps tendon

A small RC tear; partial thickness (<1cm) includes

Tear of 1 tendon, usually supraspinatus is involved

May remain asymptomatic or mild sxs of pain

No loss of AROM (moderately strong)

A Moderate thickness RC Tear (1-3 cm) can involve

2 tendons: Supra & infraspinatus

More likely to become symptomatic

May lose AROM (lose ability to elevate shoulder)

A large tear-full/complete thickness (3-5 cm) RC tears includes

Tear or tears of 3-4 tendons: Supra/infra, & Subscapularis, long head of biceps tendon

Symptomatic

Loss of AROM (barely lift arm above chest height)

what does RC tear thickness mean?

how much of the tissue belly is torn

Cuff Disease as a whole w/ partial thickness tears

10% Can heal

10% Become Smaller

54% propagate

28% become full thickness tears

Cuff Disease as a whole w/ larger tears there is

a greater rate of progression (rest of RC must compensate)

Increase fatty infiltrate & atrophy

3-5 years

Traumatic Rotator Cuff Tearing can be from

Fall On Out-Stretched Hand (FOOSH)

Lifting injuries

Traction injuries (grab/pull on arm)

Rotator Cuff Pathologies/Dysfunction on radiograph, what is seen visually?

once is torn, the humeral head migrates superioly

Patient reported sxs of RC Pathologies/Dysfunction

Shoulder pain

pain w/ laying on the shoulder

Rotator Cuff Pathologies/Dysfunction: clinical signs

Pain w/ shoulder AROM

Weak & painful resisted testing

Full PROM (if not pain limited)

RC Tear Clinical Tests: Dx of full thickness RTC is likely if 3/4 Positive Tests [4/4 (+) variables = (+) LR 28]

Age > 65

(+) Painful Arc

(+) Infraspinatus Muscle Test (resisted ER MMT)

(+) Drop Arm Test

ROM findings & special tests for diagnosing Rotator Cuff Tear

AROM < PROM Discrepancy

(+) Drop arm test

(+) ER Lag sign

during drop arm test, a well compensated pt will use deltoid to compress humeral head into glenoid, so in order to account for this

tap the arm

Decision Making in RC Tears: Traumatic versus degenerative tears

if Traumatic → then surgery

Degenerative can be managed conservatively successfully

But may progress & require surgical intervention

Decision Making in repairing RC Tears: Demographic factors

Increased age, >70 y/o increases rate of re-tear

Comorbidities

Decision Making in RC Tears: Reparability of the cuff

Massive Tears may not be repairable

Superior capsular reconstruction?

Reverse Total Shoulder?

What is the stronger predictor of success with PT for RC tear?

Patients belief in physical therapy

PT vs Surgical Repair

No difference in pain or function at 1 yr

5-10 yr outcomes may favor RC repair

(degenerative) tears generally get worse over time, conservative management 1st, then escalate to

surgical repair if necessary

Conservative Management for higher irritability RC pts

Manage Pain: MT (neck, shoulder, spine), Modalities, Gentle Exercise

ROM: Manual therapy (GH, CT), AAROM (cane), PROM (ROM in prone too)

Strengthening: Lower Load for Cuff, Scapular strengthening, Emphasis on restoring AROM

Conservative Management for lower irritability RC pts

Manage Pain PRN

ROM: Emphasis on AAROM & AROM

Strengthening: RC & Scapular strengthening

Functional training

Rotator Cuff Repair Mini -Open (Decreasing in use)

Visualization: split deltoid in order to get to RC

Fixation: in bone trough in humerus, sutures through bone &/or suture anchors, greater fixation than arthroscopic

Surgery: Supraspinatus, Maybe infraspinatus, Typically will let you know if subscap is involved, RC Interval may be closed

Increase stability of shoulder

May increase shoulder stiffness

With Arthroscopic Rotator Cuff repair, C is best because

Visualization: Through porthole camera

Fixation: Through bony anchors (dissolve, boney healing takes over)

Advantages: Less pain, Less disruption of tissue

RC repair rehab restrictions/precautions (restrictions depend on surgeon)

No Active motion for 6 weeks (allows healing of tendon to bone, based on size of tear & whether muscle retracted)

Quality of muscle tissue will also affect restrictions

What are the RC repair rehab passive restrictions? (ROM Restrictions from surgeon, when in the ROM, tension is put on sutures)

Avoid passive IR for 4-6 weeks

Behind the back (shoulder adduction) w/ IR not allowed ~ 8 weeks

Precautions for post op RC rehab are to allow for RC healing at boney footprint. Prioritize protection of repair due to retear rates which 50% of re-tears happen in

1st 3 months

Most of rest of re-tears happen 3-6 months

Post surgical stiffness: Lower re-tear rates (2% vs 57%)

Early Vs Late Mobilization post op RC repair: Delayed mobilization for >4 weeks results in

less anatomic tearing w/ no effect on long term function

No significant impact on post surgical stiffness

Post op RC repair it is important to delay strengthening for

>8 weeks

Avoid overcoming isometrics, use iso therabands/cables

Early Rehab (0-6 weeks) Post-op Rotator Cuff Repair begin PROM at 2 weeks:

Flexion to 90°, IR to 0°, ER to 30°

AAROM >2 wks (may be delayed until 6 wks)

No strengthening, but Scapular isometrics allowed

Post Surgical Rehab of RC Repair: Middle phase (6-10 wks)

ROM: AAROM, MT, Initiate AROM

Light Strengthening: Isotonics, Scapular Strengthening

Post-Surgical Rotator Cuff Rehab Middle to Late Phase (10-16 wks) includes

ROM as needed

Progressive resistance exercise: RC, Scapular stabilizers, Prime Movers

Late-Stage Post-Surgical Rotator Cuff Rehab (>16 Weeks) includes

ROM: PRN

Progressive Resistive Exercises: RC, Scapular stabilizers, Prime Movers

Functional/Work/Sport related training